OSCE Flashcards
aortic stenosis: causes
congenital - bicuspid valve
acquired - senile calcification, rheumatic fever
aortic stenosis: differential for an systolic murmur
HOCM
VSD
aortic sclerosis
flow murmur
coarctation of the aorta
aortic stenosis: examination findings
ejection systolic murmur heart loudest in aortic area and radiating to the carotids
soft S2
slow rising pulse
narrow pulse pressure
displaced apex
aortic stenosis: presenting features
asymptomatic
dyspnoea
syncope
aortic stenosis: management
monitoring
medical management of HF
if severe or symptomatic, TAVR or surgery
aortic stenosis: investigations
Echo
ECG
CXR
mitral stenosis: presenting features
asymptomatic
dyspnoea
haemoptysis
malar flush
palpitations (AF)
mitral stenosis: causes
acquired - rheumatic fever
mitral stenosis: examination findings
Mid-diastolic murmur heard loudest at the apex, reinforced by leaning on side in expiration
loud S1
malar flush
irregular pulse (due to AF)
evidence of pulmonary hypertension (P mitrale)
signs of rheumatic fever (rash, nodules etc.)
mitral stenosis: differential for diastolic murmur
Austin-Flint murmur
Large mitral valve leaflet from endocarditis or myxoma (late diastolic murmur with mitral ‘plop’)
mitral stenosis: investigations
Echo
ECG
CXR
mitral stenosis: management
medical management of AF and heart failure
if severe or symptomatic, mitral valvuloplasty or surgery
mitral stenosis: complications
pulmonary HTN
AF
Duke’s Major Criteria for Endocarditis
- typical organism found on two blood cultures
- evidence of endocardial involvement (Echo)
2 = diagnostic
Duke’s Minor Criteria for Endocarditis
- fever >38deg
- suggestive features on echo
- predisposition (e.g. prosthetic valve, IVDU)
- embolic phenomena (Janeway Lesions, clubbing, splinter haemorrhages)
- immunological phenomenon (Roth spots, Osler nodes, vasculitis)
- atypical organisms on blood culture
5 or 1 major + 3 minor = diagnostic
Infective endocarditis: empiric antibiotics for native valve disease
amoxicillin + gentamicin
Duckett Jones Major Criteria for Rheumatoid Fever
- arthritis
- (peri)carditis
- Sydenham’s chorea
- Rheumatoid nodules
- Erythema marginatum
2 = diagnostic
Duckett Jones Minor Criteria for Rheumatoid Fever
- fever
- arthralgia (not arthritis)
- recent Strep infection (culture or raised ASOT)
- raised inflammatory markers
- ECG changes (QT or PR prolongation)
1 major + 2 minor = diagnostic
Rheumatoid Fever: management
- bed rest
- high dose aspirin
- penicillin (benzylpenicillin IV STAT + phenoxymethylpenicillin PO 10 days)
mitral regurgitation: causes
congenital - connective tissue disease
acquired - degeneration/prolapse, infective endocarditis, rheumatic fever, MI (papillary muscle rupture), dilated cardiomyopathy (annular dilatation), infiltrative (amyloid)
mitral regurgitation: examination findings
pan systolic murmur heard loudest at the apex and radiating to the axilla
soft S1, split S2
pulmonary oedema
LV dilatation
signs of endocarditis
mitral regurgitation: presenting features
asymptomatic
fatigue
dyspnoea
oedema
palpitations (AF)
mitral regurgitation: investigations
Echo
ECG
CXR
mitral regurgitation: management
medical management of AF and HF
for severe for symptomatic disease, surgical repair (occasionally consider mitral clip)
aortic regurgitation: causes
congenital - bicuspid valve
acquired - infective endocarditis, rheumatic fever, aortic root dissection, aortitis (syphillis, AS)
aortic regurgitation: presenting features
asymptomatic
dyspnoea, worse on lying flat
aortic regurgitation: examination findings
early diastolic murmur heart at LLSE, reinforced by leaning forward in expiration
+/- Austin Flint Murmur
collapsing / waterhammer pulse
wide pulse pressure
hyperkinetic, displaced apex beat
S3
Quincke’s sign (nailbed capillary pulsation)
De Musset’s sign (head bobbing)
aortic regurgitation: investigations
Echo
ECG
CXR
aortic regurgitation: management
monitoring
medical management of heart failure
for severe or symptomatic disease, aortic valve replacement
tricuspid regurgitation: causes
congenital - Ebstein’s Anomaly
acquired - pulmonary HTN (e.g. COPD), rheumatic fever, infective endocarditis (IVDU), carcinoid
tricuspid regurgitation: presenting features
asymptomatic
fatigue
dyspnoea
palpitations (AF)
epigastric pain, jaundice, ascites
tricuspid regurgitation: examination findings
pan-systolic murmur, reinforced by inspiration
raised JVP with systolic waves (V waves)
pulsative liver
ascites
peripheral oedema
pulmonary hypertension
RV heave
split S2
tricuspid regurgitation: investigations
Echo
ECG
CXR
tricuspid regurgitation: management
monitoring
medical management of AF, HF and oedema
for severe or refractory disease, valve repair or annuloplasty
tricuspid regurgitation: management
monitoring
medical management of AF, HF and oedema
for severe or refractory disease, valve repair or annuloplasty
pulmonary fibrosis: examination findings
- clubbing
- fine end-inspiratory crackles
signs of autoimmune disease (e.g. RA, SLE, sclerosis) or drug treatments (Cushingoid, slate-grey from amiodarone)
pulmonary fibrosis: causes (by distribution)
Upper Zone = CHARTS
- coal worker’s pneumoconiosis
- hypersensitivity pneumonitis
- ankylosing spondylitis
- radiation
- TB
- silicosis and sarcoidosis
Lower Zone = STAIR
- SLE
- toxins (amiodarone, methotrexate, nitrofurantoin)
- asbestos
- idiopathic pulmonary fibrosis
- rheumatoid
pulmonary fibrosis: causes (general approach)
- idiopathic
- iatrogenic (amiodarone, methotrexate, nitrofurantoin, radiation)
- inflammatory (RA, SLE, AS)
- infection (TB)
- industrial (allergic hypersensitivity pneumonitis, asbestosis, coal workers pneumoconiosis)
pulmonary fibrosis: investigations
- bloods (ESR, RF/anti-CCP, ANA/anti-dsDNA)
- ABG (evidence of respiratory failure)
- CXR
- Spirometry
- High resolution CT scan
- BAL (rule-out infection)
pulmonary fibrosis: management
Vaccination, smoking cessation and pulmonary rehabilitation
Also,
- avoid triggers
- immunosuppression if ?inflammatory
- antifibrotic
Lung transplant in end-stage
wheeze: causes
- asthma
- COPD
- bronchiectasis
- other airway obstruction (foreign body, external compression)
asthma: examination findings
may be normal!
- expiratory polyphonic wheeze
- cough
- ‘tight chest’ and hyperventilation
- atopic features
COPD: examination findings
- nebulizers / inhalers / sputum pot
- central cyanosis
- pursed lips, tripoding, accessory muscles
- tar-staining
- CO2 retention flap
- hyperexpanded chest
- hyper-resonant percussion note
- expiratory polyphonic wheeze
- crackles (consolidation)
- cough
- cor pulmonale (RV heave, oedema, raised JVP)
COPD: investigations
- bloods (FBC, CRP)
- ABG
- CXR
- ECG
- spirometry (FEV1:FVC diagnostic, FEV1 prognostic)
- alpha 1 anti-trypsin levels (young patient)
COPD: management
Vaccination, smoking cessation, pulmonary rehabilitation
Routine management involves SABA/SAMA first-line, escalate to LABA+ICS (asthmatic features) or LABA+LAMA
Treat acute exacerbations with antibiotics, oral steroids
End-stage interventions are NIV/BIPAP (in exacerbations), LTOT (if stopped smoking)
COPD: complications
acute/infective exacerbations
cor pulmonale
secondary pneumothorax
secondary polycythaemia
adrenal insufficiency (due to steroid use)
asthma: investigations
- ABG
- ECG
- CXR
- spirometry with bronchodilator reversibility
- FeNO
asthma: management (routine)
Follow NICE/BTS Guidelines
1. SABA
2. SABA/ICS MART
3. Add LABA/LAMA, step-up ICS
4. Consider LTRA
asthma: management (acute exacerbation)
Admit life-threatening asthma
Serial peak flow and ABG
O2 (aim SaO2 94%)
Bronchodilator (back-to-back nebulizer or inhaler)
Oral steroids
IV magnesium sulfate, aminophylline, adrenaline
Aim 24hrs on home medications prior to discharge
bronchiectasis: examination findings
- cachexia
- clubbing
- mixed character crackles which alter with coughing
- wheeze
- cough
- cor pulmonale
bronchiectasis: examination findings
- sputum pot
- cachexia
- clubbing
- tachypnoea
- mixed character crackles which alter with coughing
- wheeze
- cor pulmonale (RV heave, oedema, raised JVP)
bronchiectasis: causes
- idiopathic
- impaired mucociliary clearance (CF, Kartagener’s syndrome, immunoglobulin deficiency)
- infection (TB, Whooping Cough, Measles, severe pneumonia)
- inflammatory (RA)
- immunodeficiency (HIV, CLL)
bronchiectasis: investigations
- bloods (FBC, CRP, cultures)
- ECG
- CXR
- sputum culture (Haemophilus)
- spirometry (obstructive pattern)
- High resolution CT (honeycombing)
consider chloride sweat test (CF), immunoglobulin studies, mucociliary clearance study
bronchiectasis: management
Vaccination, smoking cessation, pulmonary rehabilitation
Treat infective exacerbations aggressive
Inhaled corticosteroids
Bronchodilators
bronchiectasis: most likely pathogen and empiric antibiotic for infective exacerbations
Haemophilus
In CF –> pseudomonas
Ciprofloxacin first-line (covers pseudomonas)
pneumonia: examination findings
- sputum pot (rusty –> pneumococcus)
- tachypnoea, dyspnoea
- reduced expansion
- dull percussion note
- coarse crackles
- increased vocal resonance/fremitus (tactile –> empyema)
- bronchial breathing
pleural effusion: examination findings
- tachypnoea, dyspnoea
- tracheal deviation (away from effusion)
- reduced expansion
- stony dull percussion note
- reduced vocal resonance/fremitus
- reduced breath sounds
pneumonia: investigations
- ABG
- bloods (FBC, CRP, urea, serology and cultures)
- CXR
- sputum culture
- urinary antigens
pleural effusion: causes
- cancer
- congestive cardiac failure
- liver failure
- renal failure
- connective tissue disease (RA, SLE)
pleural effusion: investigations
- ABG
- bloods (FBC, CRP, U&Es, LFTs, cultures)
- pleural aspirate (biochemistry including protein, LDH –> Light’s Criteria) +/- drainage
epigastric pain: causes
- dyspepsia
- peptic ulcer (+/- perforated)
- pancreatitis
RUQ pain: causes
- perforated ulcer
- gallstones
- hepatitis
- abscess (hepatic, subphrenic)
- retrocaecal appendix
- hepatic flexure tumour
- pyelonephritis
LUQ pain: causes
- splenic rupture or infarction
- abscess (splenic, subphrenic)
- splenic flexure tumour
- pyelonephritis
RLQ pain: causes
- appendicitis
- diverticulitis
- colitis (infectious, ischaemia, inflammatory)
- UTI or pyelonephritis
- ovarian cyst or torsion
LLQ pain: causes
- diverticulitis
- colitis (infectious, ischaemia, inflammatory)
- UTI or pyelonephritis
- ovarian cyst or torsion
diffuse abdominal pain: causes
- perforation
- obstruction
- mesenteric ischaemia
- pancreatitis
- ruptured AAA
- incarcerated hernia
- UTI
- gynaecological (ruptured ectopic, ovarian pathology, fibroids or endometriosis)
acute abdomen: investigations
- urine dip and pregnancy test
- VBG (lactate)
- bloods (FBC, CRP, cultures, LFT, amylase, U&E)
- imaging (CT > AXR)
acute abdomen: management
- A-E assessment (fluids, O2)
- Analgesia
- Preparation for theatre (NBM, fluids, catheter, Abx, G&S)
hepatomegaly: examination findings
- RUQ mass, moves on inspiration, dull to percuss
- cachexia
- jaundice (scleral icterus, excoriations)
- leukonychia, Clubbing
- Dupytren’s contracture, palmar erythema
- xanthelasma
- parotid swelling, fetor hepaticus
- ascites
- spider naevi, caput medusae
- gynaecomastia, reduced body hair
- asterixis
- encephalopathy (altered consciousness)
consider underlying causes: needle tract marks, slate-grey pigmentation (hemochromatosis), signs of HF, cachexia (HCC)
hepatomegaly: causes
- cirrhosis
- carcinoma (HCC, secondaries)
- congestive heart failure
also
- infection (Hep B, C)
- immune (PBC, PSC, autoimmune hepatitis)
- infiltrative (amyloid, myeloproliferative disease)
- PKD
hepatomegaly: investigations
- routine bloods (FBC, clotting, U&Es, LFT, glucose)
- ‘liver screen’ (pANCA, AMA, anti-SMA, anti-LMK1, HBV/HCV serology, ferritin, caeruloplasmin, A1AT, AFP)
- synthetic functions (INR, albumin, platelets)
- USS abdomen
- Ascitic tap
- ERCP (?PSC)
splenomegaly: examination findings
- RUQ mass, moves on inspiration
- anaemia
- lymphadenopathy
- purpura
- hepatomegaly
splenomegaly: causes
MASSIVE:
- myeloproliferative disorders (CML, myelofibrosis)
- infections (malaria, leishmaniasis)
MODERATE or TIP:
- myelo/lymphoproliferative disorders
- infiltration (amyloidosis)
- portal HTN
- infection (EBV, IE, hepatitis)
- haemolytic anaemia
splenomegaly: investigations
- bloods (FBC, blood film including thin and thick for malaria, viral serology)
- USS first-line, consider CT
- BM aspirate
- LN biopsy
splenectomy: indications
rupture (trauma)
haematological (ITP, hereditary spherocytosis)
splenectomy: work up
Pneumococcus, Meningococcus and Haemophilus vaccination (ideally 2 weeks prior)
Life-long penicillin prophylaxis
Medical alert bracelet
renal enlargement: causes (uni- and bilateral)
UNILATERAL
- PKD
- RCC
- simple cyst
- hydronephrosis (ureteric obstruction)
BILATERAL
- PKD
- bilateral RCC
- hydronephrosis (urethral or bladder obstruction)
- tuberous sclerosis (renal angiomyolipoma)
- amyloidosis
renal enlargement: investigations
- urine dip and MC&S
- bloods (U&Es)
- USS abdomen +/- biopsy
- CT non-contrast (stones) or urogram (malignancy)
- genetic studies (ADPKD1 or 2)
